Traumatic Knee Injury Patterns in Anatolian Folk

REVIEW PAPER

International Journal of Occupational Medicine and Environmental Health 2019;32(5):585 – 593 https://doi.org/10.13075/ijomeh.1896.01398

TRAUMATIC KNEE INJURY PATTERNS IN ANATOLIAN FOLK DANCERS: A CASE SERIES AND LITERATURE REVIEW NESLIHAN AKSU1, BUSRA AKGONUL2, TANER AKSU3, VEFA ATANSAY1, and AYHAN NEDIM KARA1 1 Istanbul Bilim University, Istanbul, Turkey Faculty of Medicine, Department of Orthopedics and Traumatology 2 Sisli Florence Nightingale Hospital, Istanbul, Turkey Department of Physical Therapy and Rehabilitation Department 3 Bahcesehir University, Istanbul, Turkey Medical Faculty, Orthopedics and Traumatology Department

Abstract Lower extremities, especially the knee region, are susceptible to traumatic injuries because of long-lasting hard landings and impacts. Most of the injuries described in the literature are associated with ballet. In this review study, the authors tried to present the traumatic knee injury patterns of the Anatolian folk dance. The Fire of Anatolia dance group consists of 82 dancers (37 males [45.1%] and 45 females [54.9%]) with the mean age of 27.96 (SD = 5.05) years (range: 18–38 years). The major folk dances of the region are Zeybek, Halay, Horon, Teke, Roman, Karsilama, Bar and Lezginka (“the Caucasian”). The dancers suffered from 9 orthopedic injuries requiring surgical treatment (3 meniscus tears, 4 anterior cruciate ligament tears, 1 posterior cruciate ligament tear, 1 patellar dislocation) during a 10-year period. The authors investigated solely the traumatic injuries of these folk dance styles and aimed at revealing the traumatic knee injury patterns in this case series and literature review. On the one hand, the Anatolian folk dancers experienced meniscus tears following frequent squats and twists on single leg stances, typical of Horon and Zeybek. On the other hand, anterior cruciate tears happened after jumps and landings in the Caucasian (Lezginka jump) dance. A posterior cruciate ligament tear was also seen after the Caucasian dance landing. The split figure in the Karsilama dance ended up with patellar dislocation. Certain dance figures seem to be related to specific types of injuries. Int J Occup Med Environ Health. 2019;32(5):585 –93

Key words: dance injury, patellar dislocation, meniscus tear, knee injury, anterior cruciate ligament injury, posterior cruciate ligament injury

INTRODUCTION previous studies (7–29%) [1–6]. Knee problems account Most of the injuries described in the literature are associ- for 14–20% of all complaints and > 50% of them are ret- ated with ballet [1–8]. In the present study, the foot and ropatellar (synovial plica, medial chondromalacia, lateral ankle was the most common site (40%), which falls within patellar facet syndrome, patellar subluxation, fat pad syn- the range reported in previous studies (15–66%) [1]. In the drome) in ballet dancers [7]. Knee injuries in ballet danc- present study, the knee was the third most commonly in- ers have been reported in the literature with the following jured location (16%), falling within the range reported in prevalence: peripatellar knee pain (51–57%), ligamentous

This article’s abstract was presented for an oral presentation at the APOA (20th Asia Pacific Orthopaedic Associations) 2018 Conference. Received: October 28, 2018. Accepted: July 10, 2019. Corresponding author: Neslihan Aksu, Istanbul Bilim University, Faculty of Medicine, Department of Orthopaedics and Traumatology, Abide i Hurriyet Cad No 164 Sisli 34381 Istanbul, Turkey (e-mail: [email protected]).

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sprain (10–24%), patellar tendinitis (8–15%), iliotibial Anatolian folk dances band syndrome (4–11%), pes anserine tendinitis (2–5%), The major folk dances in the Anatolian region are Zey- popliteal cyst (0–2%), and torn meniscus (1–2%) [7]. The bek, Halay, Horon, Teke, Roman, Karsilama, Bar and the prevalence of injuries sustained by professional dancers Lezginka (“the Caucasian”) [10–14]. The Fire of Anatolia belonging to a major Spanish ballet company practicing dance group is a leading professional dance group of the classical, neoclassical, contemporary, and Spanish dance region, which performs dances of various ethnic groups were acute traumatic in 24.7%, and nontraumatic overuse which have dwelt in Anatolia for centuries and still live to- in 75.3% of the cases [8]. This study showed that 18% of gether. The names of the folk dances in this region, based the 366 injuries were in the knee region which included on their region of origin, are as follows: Zeybek (Aegean patellofemoral syndrome (8.2%), patellar tendinitis and Western Anatolia), Halay (Central and Southern (6.8%), chondral lesions (3%), and quadriceps muscle in- Anatolia), Horon (Eastern Black Sea), Teke (Southern jury (1.1%) [8]. Anatolia), Roman and Karsilama (Thracian), Bar (North- The literature is scarce, with only 2 articles concerning ern Anatolia), and Lezginka (Eastern Anatolia) [10–14]. traumatic knee injuries leading to surgery in this group While the boundaries of the dances can be defined as of patients. One of them was written by Mauffels [9] and above, it is hard to establish a definite boundary for the included 4 professional ballet dancers who had their an- Anatolian folk dances. The music has a 6/8 rhythm, the terior cruciate ligament reconstructed, and the other was melody is clear and dynamic, and the pace is fast [11]. drawn up by Aksu [10] and provided descriptions of knee Halay is the most widely known and performed type of the injuries in 7 professional folk dancers (2 anterior cruci- Anatolian folk dances. During the dance, male and female ate ligament injuries, 1 posterior cruciate ligament recon- dancers are lined up in turns to form a straight line while struction, 3 meniscus repair cases, and 1 medial patello- holding each other by the hand. The dance starts with slow femoral ligament repair). In this case series and literature steps and gradually speeds up. The steps of the Halay dance review study, the authors tried to present the traumatic are usually based on foot figures [11–14]. The final dance knee injury patterns typical of the Anatolian folk dance. in this dance group is Garzane Halay, taking its name from the Garzane region of the Bitlis Province in Eastern Ana- METHODS tolia [12]. There are consistent shoulder shakes, hard foot The Fire of Anatolia dance group consists of 82 dancers figures and soft head movements in the Garzane Halay. (37 males [45.1%] and 45 females [54.9%]) with a mean In the finale, the dancers hold each other by the hand and age of 27.96 (SD = 5.05) years (range: 18–38 years). The jump together; this is called the Garzane jump. The moves dancers suffered from 9 orthopedic injuries requiring in the Bitlis Halay are rich in terms of choreography. There surgical treatment (3 meniscus tears, 4 anterior cruciate are several forms of line-ups. The dancing couples jump ligament tears, 1 of which involved a posterolateral cor- and clap while standing next to each other [12]. ner tear, 1 posterior cruciate ligament tear, and 1 patellar Horon is a lively folk dance of the Black Sea region of dislocation) during a 10-year period. The authors inves- Anatolia, performed to kamancheh and drum music. The tigated solely the traumatic injuries of these folk dance physical features of Horon dancers are anthropometrical- styles and aimed at revealing traumatic knee injury pat- ly more defined than those of Halay dancers, thanks to the terns. They had previously obtained informed consents of high tempo of the music [12–14]. Their body fat percent- all the subjects involved in this study. ages and circumferences are lower than those of the Halay

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dancers [12,14]. Dancers in this group can reach a pace joint. Meniscal injuries typically occur following the en- of 218 steps/min during performance as was recorded by trapment of the meniscus between the femoral condyle a step counter [11]. and the tibial plateau during a turn on a flexed knee. Zeybek is a folk dance of the Aegean region. The dance A forceful flexion causes pain in the posterior horn rup- may be performed solo or by a circle of singles. When per- ture; similarly, a forceful extension causes pain in the an- formed by a group, dancers dance Zeybek without holding terior horn rupture. Meniscal tears result from percussive each other [12,14]. squats or from “screwing the knee” to increase turnout in Bar is one of the folk dances of the Northeastern Anato- ballet trainees [15]. lia. Dancers form lines to perform these esthetic dances In folk dances, meniscal tears occur due to forceful squat- of nobility and bravery. The dances depict tales of victories ting and standing, or turning on a fixed foot. Folk dances of war, valor and heroism [12,14]. are characterized by much faster and harder knee move- Teke is a folk dance performed by Turkmens in Southern ments than ballet. The Halay and Horon dances have fast Anatolia. It has 3 main sections: wobbling, hopping on and pounding feet moves [12,13]. Horon has been shown 1 foot, and running away like a cantering horse [14]. to be the fastest dance in the world, with 218 steps/min [9]. Lezginka, also called “the Caucasian” in the Caucasus re- Unlike ballet dancers, folk dancers do not tiptoe or per- gion, is a solo pair dance. The dance is a half-solo half- form movements that force the lower extremity to exces- group performance in which young people can show their sive external rotation. Of all the Anatolian folk dances, skills individually. In some jumps, the dancer lands on his the Roman dance has particularly frequent moves with knees, jumps up and lands on his knees again [10,11]. The external rotation of the hip [12]. Dancers who cannot ad- energetic and hard jumps with aerial sideway spins are the equately perform the external rotation try to compensate it main moves of the Lezginka dance. The Lezginka moves by turning their knees, which in turn poses a risk for menis- of leaping and tiptoeing are harder and faster than the cal tears. Standing on 1 foot for a long time and performing pointe figures of ballet. turns are the basic figures of the Zeybek dance. During the dance, the groups of singles line up to form RESULTS a circle [10]. During the performance of these moves, if On the one hand, the Anatolian folk dancers involved in the dancer cannot turn his/her torso on his/her foot, he/she the study experienced meniscus tears following frequent forces the knee to execute the turn. Such a movement may squats and twists on single leg stances in the Horon and also result in meniscal tears. Modern dancers perform the Zeybek dances. On the other hand, anterior cruciate liga- squat move as they carry their partner. This move might ment (ACL) tears happened after jumps and landings in cause excessive load on the menisci and their entrapment the Caucasian (Lezginka jump) dance. A posterior cruci- further. With unfitting shoes or unsuitable floors, the shoe ate ligament (PCL) tear was also seen after the Caucasian grip of the floor may cause a forceful turn of the knee, dance landing. The split figure in Karsilama ended up with resulting in an injury. patellar dislocation. In abnormal alignment of the lower extremity, a poor technique and unbalanced flexibility will cause excessive Meniscal tears rotation of the knee, which in turn may lead to meniscal Meniscal tears in dancers may range from partial thick- tears and ligament sprains. The “swayback” knees (hyper- ness wear or tear to total avulsion of the meniscus in the extension of the knee due to excessive ligamentous laxity),

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particularly in ballet dancers, are usually associated with sideway spins are the main moves of the Lezginka dance weak leg muscles making the dancer more susceptible to (Figure 1). knee injuries [15]. Eighty percent of the ACL injuries are noncontact in- Although meniscal tears are common, lateral meniscus juries which occur due to a faulty landing after leaping. damages are more often encountered in dancing when The risk of an ACL injury in dancers is significantly lower compared to other sports. These tears are rarely acute than among those who play team sports. Those injuries and result from small recursive traumas in the knee. The in team sports have a prevalence of 1–8% whereas the “overturning” movement of the knee (seen mostly in prevalence in modern ballet is 0.4% (in 5 years) [16]. dancers), combined with the strained iliotibial band, is In another study, the prevalence of ACL injuries in ballet thought to cause a degenerative tear by entrapping the dancers during a 10-year period was reported at 7% [9]. lateral meniscus [15]. The reason for the significantly lower prevalence of ACL Three of the dancers who experienced meniscal tears injuries in dancers is the performance of the moves based had to undergo arthroscopic meniscus repair [10]. All on choreography (planned moves), training and experi- the 3 dancers with meniscal tears were males; 2 were folk ence. Sudden decelerations and turns, or the probability dancers and 1 was a modern ballet dancer. One of the of contact injuries in dancing, are much lower than in folk dancers stated that he had got a feeling of a locked competition sports. When compared to athletes, danc- knee while squatting and standing during the Horon ers learn the highly specific leaping and landing - tech dance, and could unlock it by extending his legs and shak- niques at a much earlier age to acquire an aesthetic ing them off. Another folk dancer stated that he had felt appearance [5,16–22]. sudden pain while turning his body on a single leg. The Literature descriptions of dancer injuries which necessi- modern ballet dancer claimed that he had experienced tate surgical treatment mostly come from the studies on sudden pain during the squat move while carrying his ballet groups [5,9,23]. Both gender and dance type have partner, and the pain prevented him from doing further an impact on ACL injuries. Unlike ballet dancers, mod- squat moves [10]. ern dancers may improvise during the dance and this may increase the risk for ACL injuries. Female modern dance Anterior cruciate ligament injuries performers are under a greater risk of sustaining ACL in- Lezginka (“the Caucasian”) is a solo pair dance. This juries when compared to their male counterparts and all dance resembles the macho characteristics of men from classical ballet dancers [5]. Kars, the furthest eastern province in Anatolia, and is In this series, 4 dancers had ACL injuries, all of which performed solo or in groups of young people at weddings. had occurred during the landing sequence after leaping. Men’s respect towards women, their pride and austerity For a secure landing, the knee ought to be in a flexion with their partner can easily be seen during the dance. and varus position; landing while the knee is in an ex- When dancing with his peers, the male dancer exhibits tension and valgus position is a risk factor for an ACL agile, belligerent, brave and yet aesthetic moves. The injury [9,16,24–26]. dance is a half-solo half-group performance in which Four of the dancers had ACL tears; all of them were young people can show their skills individually. The male Caucasian dancers. One of the folk dancers said that, dancers lift their arms sideways, much like the wings of when performing a solo figure, he had heard a loud an eagle [12]. The energetic and hard jumps with aerial snapping sound at landing after rotating the knee out-

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ward while in excessive hyperextension. The dancer also reported excessive hypertension (recurvatum) and in- ward angulation (varus) of the knee with sudden swelling. The other folk dancer with an ACL injury reported that his knee had twisted at landing after leaping, which also caused swelling. The Caucasian dance performer with an ACL injury also stated that his knee had twisted with outward angulation at landing and swollen. Figure 1. Energetic and hard jumps with aerial sideway spins In Caucasian dance jumps, both knees of the dancer are in the Lezginka dance in flexion while he is in the air. One of the hips is ab- ducted, flexed and rotated outward while the other is in muscles are all achievable with the application of the cor- maximum extension. Subsequently, the dancer extends rect technique. The distance between the 2 knees should both his knees and does the landing [10]. This move dis- be more than the distance between the 2 feet during land- places the dancer sidewards on the frontal plane. The ing. Landing in the varus position with a flexed hip and legs are open and both knees are in extension at land- knee will decrease the risk of ACL injury. ing. This frontal force forces one of the knees to the varus and the other to the valgus position at landing. Posterior cruciate ligament injuries Thus, the forceful external rotation in this valgus posi- These injuries are less common in dance and found more tion may tear the ACL [27]. In many sports, including often in contact sports, as a result of direct trauma to the basketball and volleyball, players move in a sagittal di- flexed knee, landing on the flexed knee with plantar flex- rection during the jump and then land. ion of the ankle, or hyperextension of the knee [15]. The 4 dancers with ACL injuries underwent arthroscopic One Caucasian dance performer in the surveyed group un- reconstruction, and they were all male. This might be ex- derwent arthroscopic PCL reconstruction with hamstring plained by the fact that male dancers do more jumping autografting due to a PCL tear. In most of the Caucasian and landing than female dancers, which is in accordance dance moves, the dancer quickly and recursively lands on with the choreography. his patella with the knee flexed. If the dancer falls on the It is important to remember some of the special occasions tibia with his knee flexed, the tibia is pushed towards the of ACL injuries in dancers. Aerobics dancers may use posterior of the femur and forces the PCL to tear [10]. knee braces whereas ballet and modern style dancers can- In the Caucasian dance moves, the dancer jumps on his not use these as they impair the aesthetic appearance and flexed knee, and quickly and recursively turns his body. The stability. The outfits of professional dancers will not allow PCL tear in the Caucasian dance performer involved in the use of such apparatus as well. In fact, there is no study the study had occurred in such movement. Due to landing in the literature confirming the preventive effect of knee on their patella, all Caucasian dance performers use knee braces when it comes to ACL injuries. braces. If the dancer falls on his flexed knee with a wrong Those injuries can end the career of a professional dancer. technique, the PCL might be torn [10]. The moves of leap- Therefore, the dancer should pay utmost attention in ing and tiptoeing are harder and faster than the pointe landing during which ACL injuries are most likely to oc- figures in ballet. In some jumps, the dancer lands on his cur. A decent landing, good proprioception and strong knees, jumps up and lands on his knees again (Figure 2).

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Figure 3. The split figure in the Karsilama dance

eral patellar dislocation [28]. Environmental factors and unfitting shoes may also cause the gripping of the shoe by the ground, thus leading to knee twisting and dislocation in turning dance moves [10]. Knee dislocation may develop without tearing of the medial retinaculum in dancers who have ligamentous laxity. The arrow shows the dancer falling on the tibia with his knee flexed; These dancers report the “protruding” feeling in their the tibia is pushed toward the posterior of the femur and forces the knees; however, there is little or no swelling or tender- PCL to tear. ness. In addition, hemarthrosis and injuries are observed Figure 2. The dancer landing on his knees in the Lezginka dance in most dancers with patellar dislocation. The medial retinacular tenderness or the retinacular defect can be pal- Figure 2 shows the Lezginka jump on the knee. This fig- pated in the injured knee. In this series, 1 female dancer ure, which involves jumping and landing on the shielded developed patellar dislocation. The dancer described patella with pads and braces on a flexed knee, may pose a twist of her knee due to a shoe-grip at the beginning of a risk of a posterior cruciate ligament tear if the dancer her split move during the Karsilama dance, followed by lands on the proximal tibia instead. a severe pain. At her presentation, the patella was dislo- cated. Reduction was performed under general anesthesia Patellar dislocation and the repair of the medial patellofemoral ligament was Patellar dislocation occurs after twisting the knee due performed subsequently. The split figure may lead to pa- to the valgus stress when the foot is on the ground, right tellar dislocation in people without any prior patellofemo- before initiating a turn or jump in the air. The required ral problems [10] (Figure 3). torque is attained by stepping the “standing” foot on the Knee ligament and meniscus injuries in dancers can be ground; the leg is rotated according to both the foot and prevented with rehabilitation programs. The main aim of the thigh, and then it is angulated. The rotation and an- these programs is to “stabilize” the soft tissues of the lower gulation of the leg in respect to the foot and the hip is extremity, to correct postural and figural deformities, and increased. Several predisposing factors, including femoral to improve the motor control, posture and balance. The trochlear dysplasia, patella alta, and lateralization of the competitive dancers have well developed abductor mus- tibial tuberosity, contribute to patellar instability and lat- cles and tensor fasciae latae, but their adductor muscles

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and medial quadriceps may be weak. Strengthening the dancers who perform dances with a high risk of injuries vastus medialis and adductor muscles, while flexing the and apply neuromuscular exercise programs to prevent lateral leg muscles, will help balance the muscles which knee injuries. are the dynamic and secondary stabilizers of the knee. Muscle balance will distribute the forces exerted on the REFERENCES lower extremity along the knee and thus cause less tension 1. Shah S, Weiss DS, Burchette RJ. Injuries in professional in the medial knee. In addition, it may reduce the risk of modern dancers: incidence, risk factors, and management. traumatic meniscus and ligament injuries. J Dance Med Sci. 2012;16(1):17–25. The correct form should be emphasized. The “turnout” 2. Costa MS, Ferreira AS, Orsini M, Silva EB, Felicio LR. Char- move should be executed from the hip, not from the knee acteristics and prevalence of musculoskeletal injury in profes- or the ankle. In case this is not possible by increasing the sional and non-professional ballet dancers. Braz J Phys Ther. ability to move the hip, a “turnout” move with a smaller 2016;20(2):166–75, https://doi.org/10.1590/bjpt-rbf.2014.0142. angle should be recognized. Neuromuscular training and 3. Ekegren CL, Quested R, Brodrick A. Injuries in pre-pro- proprioception should not be overlooked in the rehabilita- fessional ballet dancers: Incidence, characteristics and con- tion and prevention process [15]. sequences. J Sci Med Sport. 2014;17(3):271–5, https://doi. It has been shown that the ratio of ACL injuries in female org/10.1016/j.jsams.2013.07.013. athletes without plyometrics training is 0.43 whereas it has 4. Wanke EM, Koch F, Leslie-Spinks J, Groneberg DA. Traumat- dropped to 0.12 in the trained ones. The training included ic injuries in professional dance-past and present: ballet inju- instructions regarding proper jumping and landing tech- ries in Berlin, 1994/95 and 2011/12. Med Probl Perform Art. niques in the first stage, strength and agility in the second 2014;29(3):168–73, https://doi.org/10.21091/mppa.2014.3034. stage, and emphasis on the maximal jumping distance in 5. Byhring S, Bo K. Musculoskeletal injuries in the Norwegian the third stage [29]. Neuromuscular training reduces the National Ballet: a prospective cohort study. Scand J Med rate of injury by teaching the athlete to perform the cor- Sci Sports. 2002;12:365–70, https://doi.org/10.1034/j.1600- rect landing position and by increasing the dynamic stabil- 0838.2002.01262.x. ity of the knee. 6. Vassallo AJ, Hiller C, Stamatakis E, Pappas E. Epidemiology of dance-related injuries presenting to emergency departments CONCLUSIONS in the United States, 2000–2013. Med Probl Perform Art. Dancer injuries may result from insufficient muscle 2017;32(3):170–5, https://doi.org/10.21091/mppa.2017.3028. strength, an incorrect technique, some anatomical 7. Reid DC. Prevention of hip and knee injuries in ballet danc- changes in the body, or inadequate motor development. ers. Sports Med. 1988;6(5):295–307, https://doi.org/10.2165/ Therefore, rehabilitation programs which provide muscle 00007256-198806050-00005. strength control, postural balance, proprioception and 8. Sobrino FJ, Guillén P. Overuse injuries in professional bal- correct technical training will be much valued in prevent- let: influence of age and years of professional practise. -Or ing such injuries. thop J Sports Med. 2017;5(6):2325967117712704, https://doi. Certain dance figures seem to be related to specific types org/10.1177/2325967117712704. of injuries. It is known that neuromuscular exercise pro- 9. Meuffels DE, Verhaar JA. Anterior cruciate ligament in- grams are applied to prevent knee injuries in professional jury in professional dancers. Acta Orthop. 2008;79(4):515–8, athletes [30–33]. Likewise, it is important to inform the https://doi.org/10.1080/17453670710015517.

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